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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form pa pro)ect) <br /> L FACILITY INFORMATION <br /> FACILITY ID k(Agency Use Onl)) i <br /> BUSINESS NAME(S® u FACR.rrY NAME or DBA-Doing Buenas Aa) T- <br /> BP/Arco#7049 <br /> BUSINESS SITE ADDRESS 103 ' CITY a <br /> 800 Eas Kettleman Lane Lodi <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that sooly) 43' WORK AUTHORIZED UNDER PERMIT 4836 <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT San Joaquin County EHD <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT SR008001 5 <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Remove existing straight droptubes and replace with flapper style droptubes and remove ball-floats from all USTs. <br /> i <br /> HEu ;� � <br /> IIIA`' 9 <br /> FNVIRONME',!-J-L HEALTH <br /> M. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION <br /> MODIFICATION qts <br /> Gettler-Ryan Inc <br /> CONTRACTOR LICENSE p 4626 [CC CERTIFICATION p •2C <br /> 220793 8206719 <br /> IV.CERTIFICATION j <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency,or if required by the local agency, inspected and certified <br /> by a registered professional en per having education and ex erience with underground storage tank system installations. <br /> SIGNATU&VDF TANK O R O ENT DATE PHONE 487 <br /> l� 4/5/19 ( 916 ) 851-1830 <br /> E FIER'S NAME(print) 425 CERTIFIER'S TITLE: its <br /> L-Michael Carruth Project Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) at CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> Gettler-Ryan Inc ❑ I TANK OWNER ❑ 2.TANK OPERATOR <br /> C1 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> l ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />